Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Hanover Park during CMS and state inspections, most recent first.
Surveyors found a 20% medication error rate when an RN failed to follow physician orders for multiple residents, including giving a GI medication before a meal, not administering a PPI because it was not available, withholding ordered metformin despite no hold parameters after a blood glucose of 97 mg/dl, giving a lower-than-ordered dose of a diuretic, and not administering an ordered meclizine dose due to lack of stock. The DON later confirmed that nurses are expected to ensure medication availability, follow timing instructions such as "with meals," and administer standing orders as written. Facility policies require all medications to be administered exactly as ordered by authorized providers.
An RN repeatedly performed blood glucose testing, insulin injections, IV medication administration, and rectal cream application for multiple residents while wearing the same gloves from room to room, without performing required hand hygiene or changing gloves between residents. The RN also failed to clean and disinfect the glucometer between resident uses, despite facility policy and manufacturer instructions requiring cleaning before and after each bedside test. Interviews with the DON and ADON/Infection Preventionist confirmed that these practices did not align with the facility’s policies on glove use, handwashing, blood glucose monitoring, and Enhanced Barrier Precautions.
Surveyors found that several inhalers in use for four residents were open and not labeled with open or discard dates, despite facility policy and active medication orders. Nursing staff confirmed the lack of labeling during medication cart checks, and the DON acknowledged that all medications should be labeled as required.
Two residents were found self-administering medications without proper assessment or physician orders, including one using an inhaler for COPD and another taking bismuth subsalicylate for heartburn. Staff confirmed that no assessments or orders were in place, and facility policy requiring such assessments was not followed.
A resident with upper extremity contractures and multiple diagnoses, including multiple sclerosis and dementia, was not consistently provided with prescribed carrot hand splints or passive range of motion (PROM) exercises as documented in their care plan and physician orders. Despite clear instructions and task assignments for CNAs, the splints were not observed in use during most surveyor visits, and the resident reported that staff did not apply the splints or perform hand exercises.
Nursing staff failed to administer medications as ordered, including omitting a scheduled nasal spray due to unavailability, giving an incorrect dose of a supplement, not instructing a resident to rinse after inhaler use, and administering an antihypertensive without checking blood pressure as required. These actions resulted in a medication error rate exceeding 10%.
A resident with a history of falls and traumatic brain injury did not receive updated fall prevention interventions after experiencing a fall in the facility. Staff and family reported that no new safety measures were put in place, and the resident was observed in unsafe conditions, such as having the bed left elevated. Facility policies requiring post-fall assessment and intervention were not followed.
A resident with severe protein-calorie malnutrition and multiple comorbidities experienced significant weight loss and did not consistently receive a twice-daily nutritional supplement as ordered. Despite documentation on the MAR indicating the supplement was given, both the resident and staff confirmed it was often missed, and the resident was unaware of the daily order. Staff cited issues such as running out of the preferred flavor and admitted to not always administering the supplement.
A resident with a history of transient ischemic attack and brain aneurysm was given oxygen at 5 L/M with an empty humidifier bottle, despite a physician order for 2 L/M and facility policy requiring humidification. Staff confirmed the discrepancies in oxygen flow rate and humidifier use.
Several residents did not receive their prescribed medications, including DuoNeb, Hydrocodone-Acetaminophen, Flonase, Midodrine, Nystatin, Triamcinolone Acetonide, Diclofenac, Guaifenesin-Codeine, and Insulin Aspart, due to the facility's failure to reorder these medications before supplies were depleted. Nursing staff and the DON confirmed that medications were expected to be reordered in advance, but this did not occur, resulting in missed doses.
A resident in an LTC facility was not changed in a timely manner, leading to soaked incontinence briefs and skin excoriation. Despite the resident's call light being activated and staff acknowledging the need for timely changes, the facility was short-staffed, resulting in a delay. The resident required substantial assistance with toileting and had existing skin damage, highlighting the importance of adhering to the facility's ADL policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with wounds, as staff did not wear gowns or gloves during care. Despite orders for EBP, there were no signs or PPE outside the residents' rooms, contrary to the facility's policy.
The facility failed to provide adequate assistance with ADLs, particularly in eating and showering. Residents were unable to reach their breakfast trays, leading to missed meals, and did not receive showers as frequently as scheduled. The facility's policies on ADLs, meal service, and bathing were not effectively implemented, resulting in unmet care needs.
The facility failed to administer and document scheduled medications as ordered and did not reorder prescribed medications for several residents. An RN completed a morning medication pass without proper documentation, believing she was following a liberalized policy that was not applicable. Additionally, multiple residents did not have their prescribed medications available, including pain relief gels, insulin, and blood thinners. One resident did not receive scheduled doses of Xanax and Cefepime due to unavailability, despite the facility's policy requiring pharmacy notification of shortages.
A resident with type 2 diabetes had her blood glucose level checked by an LPN immediately after eating breakfast, contrary to the prescribed schedule of before meals and at bedtime. This resulted in a high reading and confusion for the resident, who understood the proper timing for such tests. The facility's policy and care plan were not followed, leading to a deficiency in care.
A facility failed to promptly respond to call lights, affecting six residents needing ADL assistance. Instances included a resident waiting over 20 minutes post-surgery for help, and another with a 10-minute delay while staff conversed. The Resident Council repeatedly raised concerns, yet no improvements were made. Family grievances highlighted neglect, with one resident found in a soiled state after a 20-minute wait. The facility's call light policy was not effectively followed, leading to care deficiencies.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in accommodating their needs. One resident was unable to reach her call light, which was hanging over a dividing wall, while another resident's call light was found on the floor under her bed. Both residents are cognitively intact and require assistance with activities. The facility's policy requires staff to ensure call lights are accessible, but this was not adhered to in these cases.
A resident reported that her heating and air conditioning unit and over bed light had been broken for at least eight weeks, despite multiple notifications to staff. The Director of Environmental Services was unaware of the issues, and the facility's Work Order Report showed that the problems were reported on five occasions but not addressed in a timely manner.
A facility failed to refer a resident for a Level II PASARR evaluation after the resident was diagnosed with a new mental disorder. The resident was initially admitted with Type 2 Diabetes Mellitus and later diagnosed with a Psychotic Disorder and Major Depressive Disorder. Despite these new diagnoses, the facility did not initiate a Level II PASARR evaluation, as required by their policy. Interviews revealed staff confusion about the necessity of a Level II PASARR following new mental illness diagnoses after admission.
A facility failed to follow professional standards during blood glucose monitoring for two residents with type 2 diabetes. An RN used alcohol wipes instead of gauze to clean the first drop of blood, contrary to facility policy, potentially leading to inaccurate readings. The Director of Nursing acknowledged previous in-servicing on the correct procedure.
A resident at high risk for falls fell while attempting to transfer to the toilet after her call light went unanswered for an hour. She injured her right hip during the fall. The facility's DON and Administrator stated that residents should receive timely assistance, but the resident's needs were not met, violating the facility's fall prevention policy.
A resident experienced unmanaged severe pain due to a lapse in receiving prescribed Percocet medication, resulting in a pain level of 10 out of 10. The resident went over 24 hours without the medication, despite being regularly administered 5-6 doses daily. The facility's records showed a gap of over 27 hours between doses, and the resident was given acetaminophen for severe pain, contrary to its intended use for mild pain. The facility's pain management policy was not effectively implemented, leading to this deficiency.
A resident's personal refrigerator contained expired yogurt and moldy ham and cheese, despite the facility's policy requiring staff to check and remove expired food. The resident, who is cognitively intact, was unaware of the expired items, believing staff checked the refrigerator daily.
A facility failed to provide proper incontinence care, with multiple residents found wearing two briefs instead of one, against policy. Staff inconsistencies and lack of documentation in care plans contributed to this deficiency, affecting residents with various medical conditions requiring substantial assistance.
A resident with diabetes and other health conditions did not receive insulin as prescribed, leading to uncontrolled blood glucose levels. Insulin was administered after meals instead of before, and doses were given late, contrary to the physician's orders. The facility's policies on medication administration were not followed, resulting in significant medication errors.
Medication Administration Errors and Unavailable Medications Leading to Elevated Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 20%, with 5 errors out of 25 opportunities, involving four residents during a medication pass. For one female resident with spinal stenosis and GERD, the physician ordered metoclopramide 10 mg to be given by mouth with meals and pantoprazole 40 mg twice daily. During observation, the RN administered metoclopramide before the resident had started eating her dinner, and pantoprazole was not given as scheduled because it was not available and had only been reordered that day. The RN stated that medications are reordered when there are five pills remaining in the medication card. Another female resident with type 2 diabetes mellitus and diabetic neuropathy had an order for metformin 500 mg twice daily without parameters to hold the medication. After obtaining a blood sugar of 97 mg/dl, the RN withheld the metformin, stating the blood sugar was good, usually low, and trending low. A male resident with a history of atherosclerotic heart disease and traumatic subdural hemorrhage had an order for bumetanide 1.5 mg twice daily, but was administered only 1 mg. A female resident with hypotension, syncope, heart failure, and Meniere’s disease had an order for meclizine 12.5 mg twice daily, but the medication was not available during the medication pass and had been reordered that day. The DON confirmed that nurses are responsible for ensuring medications are available during pass, that medications ordered with meals are given with meals, and that standing orders such as metformin must be administered as ordered unless parameters to withhold are specified. Facility policies require that all medications be administered as ordered by authorized health care professionals.
Failure to Follow Hand Hygiene, Glove, and Glucometer Disinfection Protocols During Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies related to hand hygiene, glove use, and glucometer disinfection during medication administration. During an observation period on 03/02/2026, an RN (V5) performed multiple blood glucose (accucheck) tests and administered various medications, including insulin, IV Daptomycin, and rectal hydrocortisone cream, for several residents without changing gloves between residents or performing hand hygiene as required. V5 first performed an accucheck and administered insulin and IV Daptomycin for one resident (R23), then returned to the medication cart and continued to handle supplies and medications while still wearing the same gloves. V5 then prepared and administered rectal hydrocortisone cream to another resident (R125) by placing a second pair of gloves over the original pair, applying the cream to the resident’s rectum, and removing only the top pair of gloves afterward, leaving the original contaminated gloves in place. With those same gloves, V5 continued to prepare and administer medications and perform accuchecks for additional residents (R82, R99, R49, R86, R74, and R38). Throughout these activities, V5 did not remove gloves between residents, did not perform hand hygiene between tasks or residents, and walked from room to room and in the hallway wearing the same gloves, contrary to the facility’s glove and handwashing policies that require gloves to be discarded in the resident’s room, not worn from room to room, and that hands be washed after glove removal and before and after resident contact and procedures. In addition, the glucometer used for blood glucose monitoring was not cleaned or disinfected between resident uses as required by both the facility’s blood glucose monitoring policy and the manufacturer’s guidelines. V5 repeatedly removed the glucometer and supplies from the medication cart, performed accuchecks on multiple residents, and then returned the glucometer to the cart without sanitizing it before or after use. Interviews with the DON (V2) and the ADON/Infection Preventionist (V3) confirmed that facility policies require appropriate PPE use for blood glucose monitoring, cleaning glucometers per manufacturer recommendations prior to bedside testing, and adherence to Enhanced Barrier Precautions, including glove and gown use for certain high-contact care and hand hygiene with glove changes between residents. These observed practices were inconsistent with the written policies and manufacturer instructions.
Failure to Label Opened Inhalers with Open or Discard Dates
Penalty
Summary
Surveyors observed that multiple residents' inhaler medications, including Advair, Albuterol, Trelegy, and Breyna, were found open and not labeled with either open or discard dates on various medication carts throughout the facility. These observations were made in the presence of nursing staff, including both LPNs and RNs, who confirmed that the inhalers were open and lacked the required labeling. The residents involved had active physician orders for these inhalers, and the medications were in use at the time of the survey. The Director of Nursing confirmed that facility policy requires all medications, including inhalers, to be labeled with open dates to ensure safe storage and use, in accordance with manufacturer or supplier recommendations. Despite this policy, the survey found that the labeling procedure was not followed for the inhalers in question, resulting in a failure to comply with accepted professional principles for medication storage and labeling.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for the ability to self-administer medications, as evidenced by two residents who were found to be self-administering medications without proper assessment or physician orders. One resident, who had a diagnosis of chronic obstructive pulmonary disease, was observed using an albuterol inhaler provided by the facility without a documented order to self-administer or store the medication at bedside. The resident's care plan and records did not indicate any assessment or approval for self-administration of medication. Another resident was found with a bottle of bismuth subsalicylate at her bedside, which she reported taking for heartburn and had brought from home. There was no physician order for this medication or for self-administration, and no assessment had been completed to determine her ability to self-administer. Staff interviews confirmed that residents were not allowed to self-administer medications without an assessment and physician order, and that medications found at bedside would be removed. The facility's policy requires an assessment and physician order for self-administration, but this process was not followed for the two residents involved.
Failure to Provide Prescribed Splinting and Restorative Care for Contracture Management
Penalty
Summary
A deficiency was identified when a resident with contractures in both hands was not consistently provided with the prescribed carrot hand splints intended to prevent further worsening of contractures. During multiple observations over three days, the resident was found in bed without the carrot splints in place, except for one instance. The resident reported that staff never put the splints on or provided hand exercises. The care plan, physician orders, and occupational therapy recommendations all specified the use of bilateral carrot splints for up to eight hours daily, with skin integrity checks before and after use. The facility's electronic records and task lists for CNAs also documented the requirement for passive range of motion (PROM) exercises and splint use as part of the resident's restorative care. Despite these documented requirements, the splints were not observed on the resident during most surveyor visits, and the resident confirmed a lack of consistent application and exercises. The LPN/Restorative Nurse acknowledged that CNAs were responsible for providing restorative care and applying the splints, but this was not being carried out as ordered. The resident's diagnoses included multiple sclerosis, dementia, and other conditions contributing to upper extremity impairment, making adherence to the prescribed interventions critical for contracture management.
Medication Administration Errors and Noncompliance with Physician Orders
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.53% (4 errors out of 38 opportunities) during a medication pass observed by surveyors. In one instance, a registered nurse did not administer a resident's scheduled dose of Flonase nasal spray at 9 AM because it was unavailable, despite an active order for the medication. The omission was confirmed through review of the resident's electronic medication administration record (EMAR) and order summary report. Another resident received the incorrect dosage of Calcium Carbonate, being given 500 mg instead of the ordered 600 mg, and was not instructed to rinse her mouth after using a Breyna inhaler as required by the medication's instructions to prevent oral fungal infection. Additionally, a third resident was administered Amlodipine, an antihypertensive medication, without the nurse checking the resident's blood pressure prior to administration, contrary to the physician's order to hold the medication if systolic blood pressure was less than 90. The facility's policy requires that all medications be administered safely and according to physician orders.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate safety measures for a resident with a history of falls and traumatic brain injury. The resident, who was admitted from the hospital after a fall resulting in a brain bleed, also had multiple diagnoses including pneumonia, difficulty walking, lack of coordination, COPD, diabetes, congestive heart failure, hypertension, and kidney failure. Despite the resident's known fall risk and a recent fall within the facility, no new fall interventions were put in place after the incident. Family members expressed concern that no visible safety devices or interventions had been added, and staff interviews confirmed that no updates were made to the resident's care plan or interventions following the fall. Observations revealed that the resident's bed was left in an elevated position with his feet hanging off the side, and staff needed to be called to reposition him safely. Staff members, including CNAs and RNs, were unaware of any new fall interventions and did not reference a care card for safety measures. The DON acknowledged that the resident's prior fall history should have been included in the initial assessment and that interventions such as keeping the bed in a low position and offering assistance after meals were not consistently implemented. Facility policies required assessment and intervention after each fall, but these were not followed for this resident.
Failure to Provide Ordered Nutritional Supplement for Resident with Weight Loss
Penalty
Summary
A resident with a history of severe protein-calorie malnutrition, spinal infarction, paraplegia, stage 2 chronic kidney disease, neurogenic bowel and bladder, congestive heart failure, hypertension, atrial fibrillation, obstructive sleep apnea, coronary artery disease, and depression experienced a significant weight loss of 26 pounds (13.3%) over six months. The resident was cognitively intact and independent with eating. Despite a physician's order for a house supplement (such as Ensure or Boost) twice daily starting in late February, the resident reported not receiving the supplement for over a month and was unaware it was supposed to be provided daily. Interviews with nursing staff confirmed that the supplement was not consistently given, with one LPN admitting to not providing it that morning and an RN unable to recall the last time it was administered. Staff also indicated that the preferred flavor was sometimes unavailable, and the supplement was not always provided as ordered. The Medication Administration Record (MAR) for April showed staff, including the LPN and RN, were signing off that the supplement was given, despite the resident's statements and staff admissions that it was not consistently provided. The resident's care plan and progress notes documented the need for nutritional supplementation to address the risk of further weight loss. Facility policy required investigation and intervention for significant weight loss, but the failure to provide the ordered supplement as documented contributed to the resident's ongoing nutritional risk.
Failure to Follow Physician Orders and Proper Oxygen Administration Procedures
Penalty
Summary
The facility failed to follow physician orders and care plan interventions for a resident requiring oxygen therapy. A female resident with a history of transient ischemic attack and brain aneurysm was observed receiving oxygen via nasal cannula at 5 liters per minute (L/M), despite a physician order and care plan specifying oxygen at 2 L/M to maintain oxygen saturation above 92%. Additionally, the resident's oxygen was administered with an empty humidifier bottle, contrary to facility policy and staff statements that the humidifier should be filled with distilled water to prevent drying of the nares. Staff interviews confirmed the humidifier was empty and that the oxygen flow rate did not match the physician's order.
Failure to Reorder and Provide Prescribed Medications
Penalty
Summary
The facility failed to ensure the timely reordering and availability of prescribed medications for multiple residents. During observations and record reviews, it was found that one resident did not have access to their ordered DuoNeb and Hydrocodone-Acetaminophen, as confirmed by a registered nurse who reconciled the resident's medication orders with the medications on hand. Another resident missed a scheduled dose of Flonase nasal spray, and upon further review, it was determined that Flonase, Midodrine, Nystatin, and Triamcinolone Acetonide were not available for administration as prescribed. A third resident was also found to be without several ordered medications, including Diclofenac, DuoNeb, Guaifenesin-Codeine, and Insulin Aspart, as verified by a registered nurse through reconciliation of the order summary and available medications. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for nurses to reorder medications before supplies were depleted to ensure continuous availability for administration. The facility's policy on medication availability requires staff to inform the pharmacy of shortages or limited supplies. Despite these policies, the prescribed medications for the affected residents were not reordered in a timely manner, resulting in their unavailability at the time of administration.
Failure to Timely Change Incontinence Briefs
Penalty
Summary
The facility failed to ensure timely changing of incontinence briefs for a resident, identified as R3, who was unable to perform activities of daily living independently. On the morning of December 9, R3's call light was activated, and she reported needing her wet diaper changed, stating she had been wet since early morning. Despite her call light being answered once, no staff returned to assist her for over an hour. When a CNA finally arrived to change her, R3's brief, disposable pad, and cloth draw sheet were found to be soaked with urine, and her buttocks were red and excoriated. The facility's staff, including a CNA and the Director of Nursing, acknowledged the need for timely changes when residents are wet. However, the CNA mentioned that they were short-staffed on the day of the incident. R3's admission record indicated she required substantial assistance with toileting hygiene and was at risk for skin integrity issues, with existing moisture-associated skin damage. The facility's policy mandates that activities of daily living, such as changing incontinence briefs, should be adequately met, which was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for three residents who required such measures due to their medical conditions. Observations revealed that there were no signs indicating isolation needs on the doors of the residents' rooms, and no personal protective equipment (PPE) was available outside their rooms. Specifically, one resident with amputated toes that got infected, another with a surgical incision on her leg, and a third with a bandaged leg wound were not provided with the necessary EBP, as staff did not wear gowns or gloves during care activities. The Infection Prevention Nurse confirmed that staff are required to wear gowns and gloves when providing activities of daily living care to residents on EBP, especially those with open wounds or external devices. Despite orders for EBP being in place for these residents, the facility did not adhere to its own policy, which mandates gown and glove use during high-contact care activities. The facility's Enhanced Barrier Precautions List included these residents, yet the necessary precautions were not observed during the survey.
Deficiencies in ADL Assistance and Shower Schedule
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, specifically in the areas of eating and showering. Observations revealed that residents were unable to reach their breakfast trays, resulting in missed meals. For instance, one resident was found in bed with an untouched breakfast tray out of reach, expressing hunger and difficulty in locating utensils due to visual impairment. Another resident, who was confused and non-interviewable, was also unable to reach her breakfast tray, which remained untouched. These instances indicate a lack of proper setup and assistance for residents who require help with eating. Additionally, the facility did not adhere to its shower schedule, as several residents reported not receiving showers as frequently as planned. One resident mentioned not having a shower for two weeks, while another had not received a shower in 18 days. The facility's policy states that residents should receive showers twice a week, yet documentation and resident interviews revealed inconsistencies in following this schedule. This lack of adherence to the care plan resulted in residents not receiving the necessary hygiene care. The facility's policies on ADLs, meal service, and bathing were not effectively implemented, leading to deficiencies in resident care. The Director of Nursing acknowledged the need for assistance with eating to ensure residents receive warm food and meet their nutritional needs. However, the observed practices did not align with the facility's policies, resulting in unmet care needs for residents requiring assistance with ADLs.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to administer and document scheduled medications as ordered for residents, as well as reorder prescribed medications. During an observation, a registered nurse (RN) was found to have completed her morning medication pass without documenting the administration of 9 AM medications for several residents. The RN believed she was following a liberalized medication administration policy, which was not applicable to medications with increased frequencies. The facility's policy required a physician order for liberalized medication administration, which was not present for the residents in question. Additionally, the facility failed to ensure the availability of prescribed medications for several residents. During a reconciliation of electronic medication administration records (EMARs) with available medications, it was found that multiple residents did not have their prescribed medications available, including pain relief gels, insulin, and blood thinners. The facility's policy required informing the pharmacy of medication shortages, which was not adhered to, resulting in residents not receiving their medications as ordered. One resident, who had been admitted with diagnoses including anxiety and a urinary tract infection, did not receive scheduled doses of Xanax and Cefepime due to unavailability. Progress notes indicated that the medications were not administered on multiple occasions because they were not available. The Assistant Director of Nursing (ADON) acknowledged that nurses had access to a medication convenience box and were expected to follow up with the pharmacy to ensure medication availability, which was not done in this case.
Failure to Monitor Blood Glucose Levels as Ordered
Penalty
Summary
The facility failed to monitor a resident's blood glucose level as ordered, which led to a deficiency in the quality of care provided. The resident, who has a diagnosis of type 2 diabetes and is cognitively intact, was supposed to have her blood glucose levels checked before meals and at bedtime. However, on one occasion, a Licensed Practical Nurse (LPN) checked the resident's blood glucose level right after she finished eating breakfast, resulting in a high reading of 270 mg/dL. The resident, who is Spanish-speaking, attempted to explain to the LPN that the timing of the test was inappropriate, as blood glucose levels should not be checked immediately after eating. The resident expressed confusion about why her blood glucose was checked post-meal, despite her understanding of diabetes management. The facility's policy and the resident's care plan both indicated that blood glucose monitoring should occur before meals and at bedtime, yet this was not adhered to. The facility's meal service schedule also showed that breakfast was served later than when the test was conducted, further indicating a deviation from the prescribed monitoring schedule. This oversight in following the physician's orders and care plan led to the deficiency noted in the report.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to promptly respond to residents' call lights, impacting six residents who required assistance with activities of daily living (ADLs). On multiple occasions, call lights were left unanswered for extended periods, leaving residents without necessary assistance. For instance, one resident, who had undergone recent foot surgery and required a mechanical lift for mobility, waited over 20 minutes for assistance after filling urinals and needing help to get out of bed. Another resident, who was cognitively intact but dependent on staff for toilet hygiene, had their call light ignored for 10 minutes while staff engaged in personal conversations at the nurse's station. The issue of delayed call light response was a recurring concern among residents, as evidenced by the Resident Council President's complaints. Despite raising the issue in council meetings over several months, no improvements were observed. The council minutes consistently documented residents' dissatisfaction with the call light response times, highlighting a systemic issue within the facility. Additionally, a former resident expressed frustration with the facility's acceptance of a 20-minute response time as satisfactory, emphasizing the urgency of assistance for needs such as using the bathroom. Family members of residents also reported grievances related to call light response times. One spouse found their partner in a state of neglect, covered in feces and soaked in urine, after waiting nearly 20 minutes for assistance. Another family member reported difficulties in reaching floor staff via phone, with their relative repeatedly calling for help without a response. The facility's policy on call light use was not effectively implemented, as staff failed to acknowledge and respond to call lights in a timely manner, leading to significant deficiencies in resident care.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, R2 and R74, which is a deficiency in accommodating the needs of residents. On July 9, 2024, R74 was observed sitting on the edge of her bed doing exercises with a Physical Therapy Assistant, and her call light was out of reach, hanging over a wooden dividing wall about two feet away. R74, who is cognitively intact and requires limited assistance for upper body activities, stated that she could not call for help as the call light had been out of reach for many days. Her medical history includes repeated falls, and she had previously demonstrated the use of call lights successfully. Similarly, on the same day, R2 was observed sitting in her wheelchair next to her bed, appearing anxious and searching for her call light, which was found lying under her bed on the floor. R2 is also cognitively intact and requires substantial assistance with lower body activities. Her medical history includes repeated falls, difficulty in walking, and morbid obesity. The Director of Nursing confirmed that all patients must have call lights within reach, and room rounds are conducted every couple of hours to ensure this. The facility's policy, revised in January 2024, mandates that staff ensure call lights are within reach for residents who can use them each time they leave the room.
Failure to Maintain Comfortable and Lit Environment
Penalty
Summary
The facility failed to provide a comfortable and appropriately lit environment for a resident, identified as R19, whose cognition is intact according to her Minimum Data Set. R19 reported that her heating and air conditioning unit, as well as her over bed light, had been broken for at least eight weeks. Despite notifying the staff multiple times and having work orders submitted, the issues remained unresolved. During an observation, the surveyor noted that the heating and air conditioning unit was set to 54 degrees but was barely cooling, and the over bed light did not turn on, resulting in dim lighting in the room. The Director of Environmental Services, V11, who has been working at the facility for three months, stated that he was unaware of the issues with R19's room. He acknowledged that any non-functioning light should be fixed immediately and mentioned that he had informed management about the need for new fixtures in some rooms a month prior. The facility's Work Order Report showed that R19 had reported the issues on five occasions, but they were not addressed within a reasonable timeframe as per the facility's policy. The Administrator, V1, confirmed that maintenance is responsible for reviewing all work orders.
Failure to Conduct Level II PASARR Evaluation for Resident with New Mental Disorder
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation and determination after the resident was diagnosed with a newly evident mental disorder. The resident, identified as R38, was admitted with a primary diagnosis of Type 2 Diabetes Mellitus and had an OBRA screening completed in 2019, which did not suspect mental illness. However, the resident was later diagnosed with a Psychotic Disorder with Delusions in December 2019 and Recurrent Major Depressive Disorder in June 2021. Despite these new diagnoses, the facility did not initiate a Level II PASARR evaluation as required by their policy. Interviews with facility staff revealed a lack of understanding regarding the requirement for a Level II PASARR evaluation following a new mental illness diagnosis after admission. The Admissions Director was unsure if a Level II PASARR was necessary in such cases, and the Administrator incorrectly stated that PASARR is only conducted at the point of entry. The facility's policy, however, mandates a Level II review for residents with newly evident serious mental disorders. The resident's care plan indicated behavioral issues related to their mental health conditions, yet no referral for a Level II PASARR was made, highlighting a deficiency in the facility's adherence to its own policy and regulatory requirements.
Improper Blood Glucose Monitoring Procedure
Penalty
Summary
The facility failed to adhere to professional standards of care during blood glucose monitoring for two residents, R54 and R84. On July 9, 2024, a registered nurse (RN) performed blood glucose checks on these residents but did not follow the correct procedure. Instead of using a gauze to wipe the first drop of blood after pricking the finger, the RN used an alcohol wipe, which is against the facility's policy. This action was observed during the monitoring of R54, who has type 2 diabetes mellitus and requires blood glucose checks before meals and at bedtime. The RN obtained a blood sugar reading of 209 mg/dL for R54. Similarly, the RN repeated the same incorrect procedure for R84, who also has type 2 diabetes mellitus. The initial blood sugar reading for R84 was 'High,' prompting a recheck, which resulted in a reading of 600 mg/dL. The facility's Director of Nursing acknowledged that the staff had been previously in-serviced on the correct procedure, which involves using a gauze instead of an alcohol wipe to avoid inaccurate results. The facility's policy and competency validation for blood glucose monitoring emphasize the importance of allowing the puncture site to dry and using gauze to wipe the first drop of blood.
Failure to Provide Adequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident identified as R14. On July 9, 2024, R14, who was at high risk for falls, experienced a fall when attempting to transfer from her wheelchair to the toilet. R14 had used the call light to request assistance but reported that it was not answered for an hour, leading her to attempt the transfer independently. During this attempt, she fell and injured her right hip. Observations noted that R14's bed was not in a low position, which could have contributed to the difficulty in managing her needs safely. The facility's Director of Nursing (DON) and Administrator both stated that residents should have call lights within reach and receive timely assistance from staff. However, the incident report and R14's care plan, which identified her as a high fall risk, indicated that her needs were not anticipated or met, resulting in the fall. The facility's fall prevention policy, reviewed in May 2024, mandates that residents receive adequate supervision and assistive devices to prevent accidents, which was not adhered to in this case. The incident was documented in R14's progress notes, but there was no detailed description of the event aside from notifying her emergency contact.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to manage a resident's pain effectively, resulting in the resident experiencing severe pain rated at 10 out of 10. The resident, who is cognitively intact, reported going over 24 hours without receiving her prescribed Percocet medication, which was intended for severe pain management. The resident's care plan included interventions to anticipate and respond immediately to any complaint of pain, yet she was informed by a nurse that the facility was out of her medication and waiting for a pharmacy delivery. The resident's records showed she was regularly receiving Percocet, averaging 5-6 doses a day, but there was a gap of over 27 hours between doses on 7/7/2024 and 7/9/2024. The facility's Medication Administration Record (MAR) indicated that the resident received her last dose of Percocet on 7/7/2024 at 11:01 PM, and the next dose was not administered until 2:45 AM on 7/9/2024. During this period, the resident was given acetaminophen for pain rated at 9, which was not aligned with the prescribed use for mild pain. The facility's policy on pain management emphasized the responsibility of clinical staff to assess and manage pain effectively, yet the documentation showed inconsistencies in pain evaluation and medication administration, contributing to the resident's unmanaged pain.
Expired and Spoiled Food Found in Resident's Refrigerator
Penalty
Summary
The facility failed to maintain proper food safety standards in a resident's personal refrigerator, leading to a deficiency. During an initial tour, a surveyor observed expired and spoiled food items in the refrigerator of a resident who was cognitively intact, with a BIMS score of 15. The items included cartons of vanilla low-fat yogurt with past best-by dates and plastic bags containing slices of ham and cheese that emitted a foul odor and had visible mold. The resident expressed surprise that the expired items were still present, as they believed staff checked the refrigerator daily. The facility's policy requires staff, including nurses and CNAs, to ensure expired food is removed, but this was not adhered to in this instance.
Incontinence Care Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide appropriate toileting hygiene for residents requiring assistance with incontinence care. Observations revealed that multiple residents were found wearing two incontinence briefs, contrary to the facility's policy of using only one brief. This practice was observed in four residents, who were part of a sample of five reviewed for activities of daily living. The residents involved had various medical conditions, including cognitive impairments and physical dependencies, necessitating substantial assistance from staff for toileting hygiene. One resident, who was cognitively intact, reported waiting over an hour for incontinence care and noted that staff used two briefs to prevent overflow. Staff interviews confirmed that residents should be checked every two to three hours and only one brief should be used. However, there was inconsistency in practice, with some staff attributing the use of two briefs to the night shift or family preferences, although no documentation supported these claims in the residents' care plans. The facility's Director of Nursing acknowledged the issue, stating that staff should educate residents and families on the risks of using two briefs, such as skin breakdown and urinary tract infections. Despite this, the care plans for the affected residents did not document any preference for wearing two briefs, indicating a lack of adherence to the facility's incontinence care policy, which aims to keep residents dry, comfortable, and prevent skin breakdown.
Insulin Administration Errors
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with type 2 diabetes mellitus, diabetic neuropathy, hyperglycemia, congestive heart failure, cardiac pacemaker, hypertension, and chronic kidney disease stage 3. The resident, who was cognitively intact, reported that nurses administered insulin after meals instead of before, as prescribed. The resident's Physician Order Sheet indicated sliding scale Humalog insulin was to be given before meals, but the staff administered it post-meal, leading to uncontrolled blood glucose levels. On one occasion, the resident's blood glucose was 180 mg/dL in the morning, and the nurse administered insulin late, after breakfast, at 9:46 AM instead of the scheduled 7:30 AM. The nurse admitted to forgetting to administer the sliding scale dose and corrected it later, which was not in accordance with the prescribed schedule. The Medication Administration Audit Report showed discrepancies in the timing of insulin administration, with doses being signed off late. The Director of Nursing acknowledged that insufficient insulin could lead to elevated blood glucose levels, and the Medical Doctor emphasized the importance of administering insulin within a short period around meals. The facility's policies required medications to be administered as ordered, but the staff failed to adhere to these guidelines, resulting in significant medication errors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,260 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hanover Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Streamwood | 1.6 mi | ★★★★★ | 2 | 0 |
| Hearthwood Snf Senior Living | 2.6 mi | ★★★★★ | 1 | 0 |
| Abbington Vlge Nrsg & Rhb Ctr | 3.4 mi | ★★★★★ | 24 | 0 |
| Bella Terra Schaumburg | 3.9 mi | ★★★★★ | 7 | 0 |
| Encore Village | 4 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.